Failure to Develop and Implement Comprehensive Care Plans with Appropriate Interventions
Penalty
Summary
The facility failed to develop and implement comprehensive care plans with appropriate, person-centered interventions for two residents, resulting in a deficiency. For one resident with muscle weakness, right shoulder pain, osteoporosis, and dementia, the care plan did not include specific interventions for right arm and hand positioning, despite the resident being dependent on staff for care and having severely impaired cognition. Observations showed the resident's right hand was consistently red, swollen, and hanging down, and staff interviews revealed that an arm trough had been broken and removed months prior, with no alternative interventions clearly documented in the care plan or Kardex. Staff acknowledged that the care plan did not reflect the use of a pillow, teddy bear, or other positioning devices for the resident's right arm and hand. For another resident with heart disease, osteomyelitis, and urinary retention, the care plan did not address the presence or care of an indwelling urinary retention catheter, even though the resident was observed with the catheter in place and staff confirmed its use and related care needs. The Kardex also lacked any tasks or instructions for catheter care. Staff interviews confirmed that the care plan and Kardex should have included this information but did not. The facility's policy required ongoing assessment and timely revision of care plans as residents' conditions changed, but this was not followed for either resident. The lack of updated and comprehensive care plans with measurable interventions placed both residents at risk for inadequate or unsafe care, as staff did not have clear guidance on how to address their specific needs.